The paramedics arrive at your emergency department (ED) with Erin Edwards, 22, who was accidentally struck in the face with a bat during a softball game. Cervical spine precautions have been initiated.

Ms. Edwards's face is bruised on the right side. You see blood crusted on the right side of her face and her right eye is swollen shut.

Besides being potentially disfiguring, facial fractures can be accompanied by serious internal head injuries. By knowing how to deal with facial fractures in an emergency, you can help prevent or minimize disfigurement, preserve functional ability, and even save the patient's life.

In this article, I'll review facial anatomy, the causes and classifications of facial fractures, and how to manage your patient's condition in the ED and after surgery.

Complex anatomy

The face's bony structure is actually quite fragile, as it's composed of thin bones and air-filled cavities such as the mouth and sinuses (see Heads up: Common skull fracture sites). Because of its prominent location at the front of the skull, the face is prone to injury. Most facial fractures are caused by blunt trauma (such as sports injuries, falls, violence, or a motor vehicle crash [MVC]), but they can also be caused by penetrating trauma such as a gunshot wound.

The routine use of shoulder-lap restraint belts and airbag systems in motor vehicles has dramatically reduced the number of frontal facial traumatic injuries, because these safety devices prevent the face from hitting the steering wheel, dashboard, or windshield.

The amount of force needed to fracture the face may also cause other injuries. So your first step is to perform a rapid primary assessment of the entire patient to identify other potentially life-threatening injuries.

One of the biggest risks is a cervical spine or head injury. Possible head injuries include skull fractures, closed-head injuries, and disruption of the meningeal lining of the brain. Typically, patients with facial trauma are placed in cervical spine precautions (immobilization with a rigid cervical collar and secured to a backboard) until a complete assessment, including physical examination and X-rays, can exclude head and cervical spine injuries.

The forces that fracture bones also can cause massive soft tissue damage, with subsequent bleeding from the many large blood vessels in the face and head. In some situations, the bleeding may compromise the patient's airway. Surgery may be required to repair blood vessels.

Assessing your patient

Start by determining the mechanism of injury, which emergency medical services personnel may be able to provide. (Many bring digital pictures of the scene to the ED.) Understanding the likely cause of the trauma gives you clues about the type of injuries the patient could have. If she was in an MVC, find out where she was sitting in the vehicle and what happened to the vehicle. Determine if she had been using a lap-shoulder belt system and if any airbags deployed.

As always, focus on the ABCs (airway, breathing, and circulation) initially. Assess for structural damage and bleeding that could occlude the airway. Control bleeding with careful direct pressure, taking care not to cause more damage. Be prepared to remove blood with suction equipment. But never attempt to insert a nasal tube of any type (endotracheal or gastric) in a patient with facial injuries-it could pass through fracture sites and into the skull. Intubation, if indicated, should be performed via the oral route.

If the patient's face has suffered significant trauma, rapid sequence intubation using various paralytic agents may create a precarious situation: Specifically, if the patient is paralyzed but if the airway can't be successfully established, you may need to use a bag-valve-mask device-and may not be able to get an airtight seal between the mask and a mobile face. Because of this possibility, have emergency cricothyrotomy equipment readily available to establish an alternative airway if endotracheal intubation is unsuccessful.

Once the ABCs are addressed and you've completed the initial trauma survey, assess the patient's facial fractures. If she has a significant amount of facial trauma and swelling, you'll need to prepare her for a complete evaluation (including a computed tomography [CT] scan) to find all of the injuries, rather than just concentrating on the obvious facial injuries.

One of the hallmarks of trauma is asymmetry that can be seen or gently palpated. With facial fractures, the injuries may be visually obvious.

If the patient is responsive, ask if she has any pain. If so, ask about its location and characteristics such as intensity on a 0-to-10 pain rating scale. If she might have a mandibular or maxillary fracture, ask if her teeth fit together normally and if she can open and close her mouth without difficulty or pain. If she has a malocclusion (her teeth aren't aligned properly), you can assume a mandible or maxilla fracture until proven otherwise.

Another technique is to ask the patient to clench her teeth together-the pressure may cause pain at the site of injury, helping to locate injuries.

If the nose or orbit are injured, compare the position of the eyes. A fracture through the bones of the orbit may cause the injured eye to appear sunken compared to the uninjured eye.

If the patient can cooperate, ask her to look up, down, and to each side without moving her head, and observe the movement of both eyes. An orbital fracture is likely to entrap one or more of the muscles that move the injured eye, making it difficult for the injured eye to look up (the uninjured eye can complete the task).

When palpating the injuries, feel both sides of the face at the same time, comparing the injured side to the uninjured side. Asymmetry, abnormal mobility, pain, crepitus, or a palpable step-off deformity (a step where one shouldn't be; for example, along the body of the mandible) indicate possible fracture sites.

Start at the eyebrows, palpating from the nose outward. Move to the condyles of the mandible, just in front of the ear, and palpate down to the angle of the jaw. While palpating the condyles, ask the patient to open and close her mouth. Move in and across the zygomatic arch and then palpate the nose. As you move your hands across the cheeks, ask the patient if she feels normal sensation. Le Fort II and III fractures and fractures of the zygomatic bone may damage the infraorbital nerve, causing anesthesia of the inferior eyelid, part of the nose, and the superior lip. Palpate the maxilla and then move to the chin, palpating back to the angle of the mandible.

Because of the complexity of the face and skull, patients with facial fractures will usually need an X-ray or other imaging study, such as a CT scan, to determine the exact nature of the fractures. The X-ray exam may include simple anterior and posterior views and specialized views of the sinuses and mandible. Results of the physical exam can help the health care provider determine which X-rays or images are needed.

Treatment strategies

As when treating any trauma patient, insert one or two large-bore intravenous (I.V.) catheters and begin administering 0.9% sodium chloride solution or lactated Ringer's solution. Look for fluid leaking from the nose or ears. A meningeal tear, which may occur with a facial fracture, can let cerebrospinal fluid (CSF) leak from the skull into the ears or nose or, less commonly, the eyes. This fluid typically is clear, but it may be blood-tinged or pink. One simple way to identify the fluid is to place a drop on gauze or filter paper and observe. If it's mucus, the gauze will become stiff; if it's CSF, it won't become stiff. Also look for the halo sign: a ring formed when protein in the CSF migrates to edge of the wet spot as the gauze dries.

The presence of CSF indicates a basal skull fracture and meningeal tear. Don't occlude the drainage; simply place a drip pad below the nostril or ear to collect the CSF as it escapes. If occluded, the CSF will be forced back into the skull, along with whatever else is in the ear or nose, increasing the patient's infection risk. Monitor the patient for signs and symptoms of increased intracranial pressure, which may be associated with intracerebral bleeding caused by a basal skull fracture.

Many facial injuries require surgical stabilization, but this may be delayed to let swelling subside. Applying cold packs will help prevent swelling so surgery can proceed sooner.

Mandible fractures are typically stabilized with arch bars placed across the upper and lower teeth and wired together. Afterward, the patient will be on a liquid diet. Have wire cutters on the bedside at all times. If she should start vomiting, the wires must be cut immediately to protect the airway.

Maxillary fractures require surgical stabilization, which may be integrated with an arch bar across the upper teeth to stabilize any fractured teeth. Le Fort II and III fractures may cause more airway problems than other fractures simply because of their instability. They are also more commonly associated with CSF leakage than Le Fort I fractures.

Orbital fractures require surgery to stabilize the fractured bones and release entrapped ocular muscles.

Zygomatic fractures require surgical stabilization and fixation if they're depressed (which may affect appearance), or impinge on eye movement, the infraorbital nerve, or the coronoid process of the mandible. But if the fractures aren't displaced and don't affect function, they may be left alone.

Nasal fractures may be very simple, requiring only a little lateral manipulation to return the nose to a normal position. Complex nasal fractures require surgery, especially if the damage is to the bridge of the nose or if the fracture is complicated by CSF leakage.

Bleeding from a broken nose is usually stopped with direct pressure, but may require either anterior or posterior packing or the insertion of a double-balloon device or a urinary catheter with a saline-filled balloon to act as a pressure dressing.

Taking care of teeth

If the patient has tooth pain, examine the teeth, gently pressing them to assess for abnormal mobility. Also examine them for color changes. If you don't see a color difference between the fractured portion of the tooth and the rest of the enamel, then the fracture likely is just through the enamel. If you see a soft yellow substance, the fracture extends into the dentin. Pink or red pulp means the fracture extends into the pulp of the tooth.

Treatment for tooth fractures depends on the severity of the fracture. With enamel fractures, you can safely refer the patient to her dentist for evaluation at a later date. If the yellow dentine is exposed, coat the damaged teeth with calcium hydroxide paste, cover the area with aluminum foil, and refer the patient to a dentist within 24 hours for further assessment and treatment. If the pink or red pulp is exposed, arrange for an immediate consult with a dentist or oral surgeon to prevent formation of an abscess under the tooth.

An avulsed tooth needs to be replaced in its socket as soon as possible after the root has been gently rinsed with 0.9% sodium chloride solution to remove debris. Handle the tooth by the crown only; touching or scrubbing the root could reduce the chance for successful reimplantation.

If the tooth can't be replaced into the socket, place it in a glass of milk or 0.9% sodium chloride solution. If the tooth is out of the socket for more than two hours, the reimplantation rate is less than 5%.

If a tooth or part of a tooth is missing, obtain a chest X-ray to make sure that the patient hasn't aspirated it. A tooth or fragment in the respiratory tract will need to be removed via bronchoscopy.

Batter oops

Now let's return to Ms. Edwards the young woman we met at the beginning of this article. The paramedics tell you that she walked up behind the on-deck batter during a softball game and was inadvertently struck by the batter's backswing. Ms. Edwards didn't lose consciousness and remembers the event quite clearly. She's awake, alert, and responsive to your questions. Her initial survey is unremarkable, except for her facial injuries. You start an I.V. infusion of 0.9% sodium chloride solution.

Ms. Edwards complains of pain on the right side of her face and has difficulty opening her mouth, but says she can breathe easily. She also notes that she can't open her right eye. You observe a depression under her right eye when compared to the left. You also note pink drainage from her left nostril, and use a piece of gauze to catch a drop, which you set aside to let dry.

While you palpate Ms. Edwards's face, she reports significant pain on the right cheekbone and across the nose and the maxilla, and an area of numbness below her right cheek. She also complains of pain when she tries to open her mouth while you're palpating the cheekbone. You note a slight step across the zygomatic bone and find that the maxilla is slightly mobile. You can open her right eyelid; the eye appears somewhat sunken when compared to the left, and you see a lateral subconjunctival hemorrhage.

When you ask Ms. Edwards to look up, her right eye remains fixed while her left eye looks up. While you're applying an ice pack to the right side of her face, you notice that the pink drainage you placed on the gauze has dried without stiffness and you see that a ring has formed.

You report your findings to the physician, who suspects that Ms. Edwards has a basal skull fracture, a displaced fracture of the zygomatic bone, a LeFort I fracture on the right side, and an entrapped right eye. She orders a head CT scan and contacts a neurosurgeon, otolaryngologist, and ophthalmologist. Meanwhile, the radiologist calls from X-ray to report that the CT findings support the clinical assessment.

Ms. Edwards is taken to the operating room, where an arch bar is placed across her upper teeth to stabilize the maxilla and her entrapped right eye muscle is released. She's admitted to the ICU for monitoring and to let the swelling subside. Two days later, she's transferred to the medical/surgical unit. Ms. Edwards is discharged home after five days in the hospital.

Something to smile about

Facial fractures can be a formidable challenge. But by understanding how to recognize them, you can make sure your patient receives appropriate and timely care.

Maxillary fractures